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The nurse is preparing to administer a.m. medications to clients. Which medication should the nurse question before administering?
- A. Pancreatic enzymes to the client who has finished breakfast.
- B. The pain medication, morphine, to the client who has a respiratory rate of 20.
- C. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L.
- D. The beta blocker to the client who has an apical pulse of 68 bpm.
Correct Answer: A
Rationale: Pancreatic enzymes should be taken with meals, not after, to aid digestion. Morphine, diuretics, and beta blockers are appropriate based on the data.
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The nurse is caring for the client diagnosed with DI. Which nursing actions are most appropriate? Select all that apply.
- A. Monitoring hourly urine output and daily weights
- B. Checking urine osmolality and urine ketones
- C. Giving desmopressin acetate (DDAVP) as prescribed
- D. Checking glucose levels before meals and at bedtime
- E. Monitoring for signs or symptoms of hyperkalemia
Correct Answer: A,C
Rationale: Monitoring urine output and weights tracks fluid loss, and DDAVP replaces ADH in DI.
The nurse is teaching a client to self-administer insulin. The instructions should include teaching the client to:
- A. inject the needle at a 90-degree angle into the muscle.
- B. vigorously massage the area after injecting the insulin.
- C. rotate injection sites.
- D. keep the open bottle of insulin in the refrigerator.
Correct Answer: C
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption. Insulin is injected subcutaneously, not into muscle, and massaging can alter absorption.
The nurse should assess for hypocalcemia based on which client statements after a subtotal thyroidectomy?
- A. I feel tingling in my hands and feet.
- B. I have a headache.
- C. I feel sleepy.
- D. I have a sore throat.
Correct Answer: A
Rationale: Tingling in the hands and feet indicates hypocalcemia, a potential complication due to parathyroid gland damage during thyroidectomy.
Which problem is most likely to develop if hyperthyroidism remains untreated?
- A. Pulmonary embolism
- B. Respiratory acidosis
- C. Cerebro vascular accident
- D. Heart failure
Correct Answer: D
Rationale: Untreated hyperthyroidism causes severe tachycardia, which can lead to heart failure due to increased cardiac workload.
Which signs/symptoms should the nurse expect to assess in the 31-year-old client who has a sustained release of growth hormone (GH)?
- A. An enlarged forehead, maxilla, and face.
- B. A six (6)-inch increase in height of the client.
- C. The client complaining of a severe headache.
- D. A systolic blood pressure of 200 to 300 mm Hg.
Correct Answer: A
Rationale: Excess GH (acromegaly) causes facial and bone enlargement (e.g., forehead, maxilla). Height increase occurs pre-puberty, headaches are nonspecific, and extreme hypertension is unrelated.